John Singleton
Evidence boundary. This page is a structured project extraction from the linked primary Prevention of Future Deaths source. It is not the report text. Do not infer cause, prevalence or product-wide performance beyond the source and the explicit qualification below.
Open the primary Judiciary source · Source register: SRC-062 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0126 |
| Registered primary source | SRC-062 |
| Report date | 2023-11-16 |
| Coroner area | Cheshire |
| Clinical setting | Prison healthcare |
| Care transition | Medicines dispensing/collection to clinical follow-up |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Secure and custodial care |
| Predominant information boundary | Within a care setting |
The workflow, browsing-context and predominant-boundary fields are retained navigation aids. They are not additional coronial findings, and a single primary value cannot express every aspect of a multi-setting or multi-mechanism report.
Care-pathway classification
This classification distinguishes where safety-relevant information or work arose, where action was expected and where the digital or information workflow failed. It is a project coding of the source, not a coronial statement. “Origin” does not mean the organisation caused the harm.
| Dimension | Project classification |
|---|---|
| Settings and pathway participants | Prison, custody or secure healthcare |
| Information or work-item origin | Prison, custody or secure healthcare |
| Origin care context(s) | Secure or custodial healthcare |
| Expected action destination | Prison, custody or secure healthcare |
| Destination care context(s) | Secure or custodial healthcare |
| Directional pathway | Prison, custody or secure healthcare → Prison, custody or secure healthcare |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: Medication non-collection arose in prison dispensing and required prison clinical follow-up; the missing escalation was between functions in one secure healthcare setting.
Classification confidence applies only to this care-pathway coding. It is separate from extraction confidence, source authority and causal certainty.
Evidence status and qualification
| Field | Status |
|---|---|
| Extraction confidence | high |
| Verification status | Primary source linked; high-confidence extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-084 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, ALERT, IDPOP |
Qualification recorded in the dataset: Report expressly says medicines non-compliance and mental-health referral systems were lacking but did not cause or contribute to this death. NHS England preferred actionable reports over a passive record flag
“Response evidence noted” means only that the row qualification refers to response/respondent evidence or records a recipient's post-report position. The linked IDs enumerate the official response attachments registered for this row; they do not imply that every response supports every part of the qualification, and they do not establish implementation. “Not assessed” makes no claim about whether a response exists.
Structured project extraction
These fields are analytical summaries, not quotations.
Project summary of the coroner's concern
The coroner found that an automatic medication non-collection warning was neither possible nor available
Requested action
NHS England to enable more efficient early identification and action when prison medicines are not dispensed or collected
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | SystmOne Health and Justice Information Service |
| Digital function | Medication non-collection detection, alerting and population worklists |
| Failure mode | The system could not automatically identify and flag failed dispensing or collection for prompt clinical action |
| Human-factors issue | A patient-record flag would be passive until the record was opened; in-possession collection dates did not necessarily equal dose-due dates |
| Workflow issue | Detection relied on local reports, supply-room checks and provider processes rather than an automatically owned exception workflow |
| Information issue | Medication non-collection and possible non-adherence were not surfaced consistently at population level |
Downstream Defence trace
No canonical candidate Defence requirement currently cites this report. This does not imply that the mechanism is irrelevant; any mapping must be added and qualified in the controlled requirements register.
The included-case dataset preserves early legacy_military_relevance and legacy_derived_requirement fields for audit history. They are not published here as requirements and must not override the canonical REQ register. New report rows do not need to populate them.
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